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Living Will Form (Health Care Directive)

A living will or health care directive allows a person (principal) to create end-of-life treatment preferences. The main purpose of a living will is used to direct medical staff on whether to provide or remove life-sustaining procedures. A living will only becomes effective if a person is deemed to have a terminal or incurable condition.
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Signing Requirements – Must be signed in accordance with State law.

By State

What is a Living Will?

A living will is a declaration that instructs medical staff on how to treat a person (declarant) in a terminal or incurable condition. The document will include whether the declarant accepts or rejects life-sustaining procedures.

Video

Statutory Forms

STATE STATUTORY FORM LAWS
 Alabama Advance Directive for Health Care § 22-8A-4
 Alaska Advance Health Care Directive Sec. 13.52.300
 Arizona Living Will § 36-3262
 Arkansas Declaration of Living Will § 20-17-202
 California Advance Health Care Directive PROB § 4701
 Colorado Declaration as to Medical or Surgical Treatment § 15-18-104
 Connecticut Declaration to Remove Life Support System Sec. 19a-575
 Delaware Advance Health Care Directive § 2505
 Florida Living Will § 765.303
 Georgia Advance Directive for Health Care § 31-32-4
 Hawaii Advance Health Care Directive Form § 327E-3
 Idaho Advance Care Planning Document § 39-4510
 Illinois Living Will Declaration 755 ILCS 35/3
 Indiana Living Will Declaration § 16-36-4-10
 Iowa Declaration Relating to Use of Life-Sustaining Procedures § 144A.3
 Kansas Living Will Declaration § 65-28,103
 Kentucky Advance Directive § 311.625
 Louisiana Living Will Declaration

RS 40:1151.2

 Maine Health Care Advance Directive Form § 5-803
 Maryland Advance Directive § 5-603
 Massachusetts Living Will Directive No statute
 Michigan Living Will No statute
 Minnesota Health Care Directive § 145C.16
 Mississippi Advance Health Care Directive § 41-41-209
 Missouri Health Care Directive § 459.015
 Montana Living Will Declaration § 50-9-103
 Nebraska Living Will Declaration § 20-404
 Nevada Declaration/Living Will  NRS 449A.439
 New Hampshire Advance Directive
Section 137-J:20
 New Jersey Living Will Declaration

Section 26:2H-54

 New Mexico Advance Directive for New Mexico § 24-7A-4
 New York Living Will § 400.21
 North Carolina Advance Directive for a Natural Death (“Living Will”) § 90-321
 North Dakota Health Care Directive § 23-06.5-17
 Ohio Living Will Declaration § 2133.02(A)(1)
 Oklahoma Advance Directive for Health Care § 63-3101.4
 Oregon Advance Directive for Health Care ORS 127.702
 Pennsylvania Living Will § 5471
 Rhode Island Living Will Declaration § 23-4.11-3
 South Carolina Living Will Declaration Section 44-77-50
 South Dakota Living Will Declaration § 34-12D-3
 Tennessee Advance Directive for Health Care § 68-11-1803
 Texas Directive to Physicians and Family (living will) Sec. 166.033
 Utah Advance Health Care Directive § 75-2a-117
 Vermont Advance Directive for Health Care 18 V.S.A. § 9703
 Virginia Advance Medical Directive § 54.1-2983
 Washington Health Care Directive RCW 70.122.030
West Virginia Living Will § 16-30-4
 Wisconsin Declaration to Physicians Living Will § 154.03(2)
 Wyoming Advance Health Care Directive § 35-22-403

How to Make a Living Will (4 steps)

  1. Decide Treatment Options
  2. Choose End-of-Life Decisions
  3. Select a Health Care Agent (Optional)
  4. Sign Form

1. Decide Treatment Options

couple reviewing treatment options on tabletTake a moment to reflect on what course of action you would like to take in the event of certain medical events that could occur such as:

  • Alzheimer’s Disease;
  • Dementia;
  • Vegetative State;
  • Coma; and
  • Incapacitation.

Depending on your individual preference would you like to have the medical staff do everything possible to keep you alive? Or, would you rather die peacefully if you cannot breathe or eat on your own?

These are questions that should be discussed between you and your family so that in the unfortunate event this should happen you and your family will be ready. After careful discussion, the final decisions you make should be reflected in the document.

2. Choose End-of-Life Decisions

person typing out end-of-life decisions on laptopIf there are any other decisions besides medical care that you would like such as a priest or religious person saying your last rights or specific funeral plans you would like to make it is best to have written to be carried out by your family.

3. Select a Health Care Agent (Optional)

couple reviewing different healthcare agents on laptopMost living wills have the option of adding a health care agent to carry out the patient’s intended wishes. This is helpful in the event that there is a gray area where maybe the agent selected feels there is a good chance for survival and will opt against a decision made in the living will. Otherwise, the Principal can choose to neglect this portion of the document and have doctors and medical staff specifically adhere to what is written in the living will.

4. Sign Form

The declarant will be required to sign the directive in accordance with the laws in the State. This most commonly involves two (2) witnesses or a notary public (or both).
State Signing Requirements Statute
 Alabama Two (2) witnesses § 22-8A-4(c)(4)
 Alaska Two (2) witnesses or a notary public AS 13.52.010(b)
 Arizona One (1) witness or a notary public § 36-3261(b)
 Arkansas Two (2) witnesses or a notary public § 20-17-202(a)(1)
 California Two (2) witnesses or a notary public PROB § 4701
 Colorado Two (2) witnesses or a notary public § 15-18-106(1)
 Connecticut Two (2) witnesses § 19a-575
 Delaware Two (2) witnesses § 2503(b)
 Florida Two (2) witnesses § 765.302(1)
 Georgia Two (2) witnesses § 31-32-5(c)(1)
 Hawaii Two (2) witnesses or a notary public. § 327E-3(b)
 Idaho The Principal is the only required signer. Although, the State of Idaho recommends it to be witnessed or notarized. § 39-4510
 Illinois Two (2) witnesses 755 ILCS 35/3
 Indiana Two (2) witnesses IC 16-36-4-10
 Iowa Two (2) witnesses or a notary public § 144.A.3(2)
 Kansas Two (2) witnesses § 65-28,103
 Kentucky Two (2) witnesses or a notary public § 311.625(2
 Louisiana Two (2) witnesses § 1151.2(A)(2)
 Maine Two (2) witnesses § 5-803(2)
 Maryland Two (2) witnesses § 5-602(c)
 Massachusetts No requirements No statute
 Michigan No requirements No statute
 Minnesota Two (2) witnesses or a notary public § 145C.03
 Mississippi Two (2) witnesses or a notary public § 41-41-209
 Missouri Two (2) witnesses 459.015(4)
 Montana Two (2) witnesses § 50-9-103
 Nebraska Two (2) witnesses or a notary public 20-404(1)
 Nevada Two (2) witnesses NRS 449A.439
 New Hampshire Two (2) witnesses or a notary public § 137-J:14
 New Jersey Two (2) witnesses or a notary public § 26:2H-56
 New Mexico Principal only. Although in § 24-7A-4(Part 3)) states that “two (2) witnesses are recommended” (§ 24-7A-2(B), § 24-7A-4(Part 3))
 New York Two (2) witnesses PBH § 2981
 North Carolina Two (2) witnesses and a notary public § 90-321(c)
 North Dakota Two (2) witnesses or a notary public § 23-06.5-05
 Ohio Two (2) witnesses or a notary public Section 2133.02(B)
 Oklahoma Two (2) witnesses § 63-3101.4
 Oregon Two (2) witnesses or a notary public ORS 127.515(2)(b)
 Pennsylvania Two (2) witnesses § 54-5442(b)
 Rhode Island Two (2) witnesses § 23-4.11-3(a)
 South Carolina Two (2) witnesses and a notary public § 44-77-40(2)
 South Dakota Two (2) witnesses and a notary public § 34-12D-2
 Tennessee Two (2) witnesses or a notary public § 68-11-1803(b)
 Texas Two (2) witnesses or a notary public § 166.154§ 166.003
 Utah One (1) disinterested witness § 75-2a-107(c)
 Vermont Two (2) witnesses 18 V.S.A. § 9703
 Virginia Two (2) witnesses § 54.1-2983
 Washington Two (2) witnesses or a notary public RCW 70.122.030(1)
Washington D.C. Two (2) witnesses 7-622(a)(4)
West Virginia Two (2) witnesses or a notary public § 16-30-4(a)
 Wisconsin Two (2) witnesses § 154.03(1)
 Wyoming Two (2) witnesses or a notary public § 35-22-403(b)

Sample

Download: PDF, MS Word, OpenDocument

HEALTH CARE DIRECTIVE (LIVING WILL) 

I, [FULL NAME] (“Principal”), want everyone who cares for me to know what health care I want when I cannot let others know what I want.

SECTION 1:

I want my doctor to try treatments that may get me back to an acceptable quality of life. However, if my quality of life becomes unacceptable to me and my condition will not improve (is irreversible), I direct that all treatments that extend my life be withdrawn.

A quality of life that is unacceptable to me means (check all that apply):

☐ – Unconscious (chronic coma or persistent vegetative state)
☐ – Unable to communicate my needs
☐ – Unable to recognize family or friends
☐ – Total or near total dependence on others for care
☐ – Other: [OTHER]

Check only one:

☐ – Even if I have the quality of life described above, I still wish to be treated with food and water by tube or intravenously (IV).
☐ – If I have the quality of life described above, I DO NOT wish to be treated with food and water by tube or intravenously (IV).

SECTION 2: (You may leave this section blank)

Some people do not want certain treatments under any circumstance, even if they might recover. Check the treatments below that you do not want under any circumstances:

☐ – Cardiopulmonary Resuscitation (CPR)
☐ – Ventilation (breathing machine)
☐ – Feeding tube
☐ – Dialysis
☐ – Other: [OTHER]

SECTION 3:

When I am near death, it is important to me that: [LIST PREFERENCES]

(This section may include preferences such as hospice care, place of death, funeral arrangements, cremation, or burial selections)

As the principal, I fully understand my rights regarding this living will and the availability of health care treatment options. I have made my selections above of my free will and without coercion from any 3rd party.

Principal’s Signature: ___________________________ Date: ____________

Print Name: ___________________________

 

Source: https://www.hov.org/media/1112/living-will_forms.pdf